Social determinants of health (SDOH) can drive up to 60% of health outcomes.1


Homelessness, poor housing conditions, and dangerous neighborhoods have all been proven to negatively impact physical and mental health.


Many people lack access to transportation to healthcare appointments, often resulting in decreased health outcomes and increased health costs.


A good education influences health over the course of a person's entire life, not just when they're in school. It's linked to the ability to secure employment, and measures like life expectancy and infant mortality.


Unemployment, job security, the work environment, and compensation and benefits can all impact physical and mental health outcomes.

Food Insecurity

When people lack access to healthy food, they are at an increased risk of obesity, poor mental health, and other chronic conditions.

Social Support

Support from family, friends, and the community is linked to better mental and physical health.

The benefits of addressing SDOH

Understanding the patient population can give MCOs and care delivery organizations better insight into the most relevant programs in which to invest.

By removing stressors such as lack of shelter, food or transportation, individuals' quality of life is improved—which can lead to better health outcomes.

Addressing barriers that stand in the way of health outcomes—such as providing housing to the homeless, connecting low-income adults with chronic illnesses to a food assistance program or helping individuals find employment—can reduce healthcare costs, emergency room visits and additional care.

5 innovative ways states are focusing on SDOH


Oregon's 1115 waiver allows for a model of managed care focusing on SDOH. The state recently signed contracts with 15 coordinated care organizations to address the social factors that contribute to the health of nearly 1 million Oregonians.2

New Mexico:

New Mexico takes a boots-on-the-ground approach, requiring MCOs to employ community health workers to help with care.3


Illinois' 1115 waiver will help Medicaid enrollees with behavioral health conditions receive substance abuse treatment, housing services, employment assistance and more.5


Florida's MCOs offer services to connect women to resources such as the Special Supplemental Nutritional Program for Women, Infants and Children (WIC).4

Rhode Island:

Rhode Island's accountable entities (AE) programs coordinate a team of providers to assess social needs, provide referrals to community resources and use community partnerships to address identified needs of the population.6

Top 6 strategies to understand and address SDOH


Start with member/patient experience to identify data about SDOH and implement interventions.

Invest in a strategy that reveals gaps in data about SDOH. A data strategy that incorporates standard terminology and coding structures to compare third-party data, such as DMV records, prison records, dental records and credit bureaus, can help Medicaid MCOs and care delivery organizations learn more about the social factors impacting members. Partnering with companies like Aveus, a division of Medecision, can help organizations devise a strategy by understanding market demographics, leveraging data to create focus, identifying funding and grant opportunities, building community partnerships, and designing operational and cultural change plans.


Build collaborative care teams.

Care team collaboration is important for ensuring that SDOH are addressed across multiple inpatient, ambulatory and community-based settings. Assign a central point-of-contact to support transitions in care and fill in the gaps.


Partner with community organizations.

Community partners can help support members and assist them in finding housing, transportation, employment, food and other resources. Some health plans are even placing navigators in the community to support SDOH and interact with community partners—a new role for many plans.


Leverage technology.

Use technology tools such as Aerial by Medecision, which brings payers, providers and community-based organizations together to address SDOH as an integrated team.


Involve individuals, caregivers and supports.

When people are connected to and educated on the resources and social supports they need, they will be more engaged in their care.


Measure your impact.

Having measurable KPIs, such as health outcomes, utilization of healthcare services and medication adherence, can help determine success and help organizations identify areas for improvement.